Inspection Report
Plan of Correction
Deficiencies: 0
Sep 3, 2025
Visit Reason
The document addresses the acceptance of a credible allegation of substantial compliance and the Plan of Correction for the survey ending July 31, 2025, certifying the facility in compliance effective August 20, 2025.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, leading to certification of compliance effective August 20, 2025.
Report Facts
Survey end date: Jul 31, 2025
Compliance effective date: Aug 20, 2025
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 7
Jul 31, 2025
Visit Reason
The inspection was conducted as an annual recertification survey and investigation of complaints #129505-C and #128445-C from July 28, 2025 to July 31, 2025.
Findings
The facility was found to have multiple deficiencies including failure to obtain informed consent for psychotropic medication changes, incomplete comprehensive assessments after significant changes, failure to complete quarterly assessments timely, inadequate ADL care for dependent residents, respiratory care issues, trauma-informed care deficiencies, and insufficient nursing staff to respond to call lights timely.
Complaint Details
Complaint #129505-C resulted in a deficiency related to failure to obtain informed consent for psychotropic medication changes.
Severity Breakdown
D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to educate resident and obtain informed consent for psychotropic medication changes for Resident #60. | D |
| Failure to complete a comprehensive assessment after significant change for Resident #2 receiving hospice services. | D |
| Failure to complete quarterly Minimum Data Set (MDS) assessments timely for 3 residents. | D |
| Failure to provide adequate ADL care including bathing for dependent residents #13 and #61. | D |
| Failure to ensure respiratory care devices were operational and maintain oxygen tubing properly for residents #1 and #18. | D |
| Failure to provide trauma-informed care for Resident #60 including addressing suicidal ideations and behavior monitoring. | D |
| Insufficient nursing staff to respond to call lights within 15 minutes for 3 observations. | D |
Report Facts
Census: 86
Deficiencies cited: 7
Psychotropic medication consents audit frequency: 3
Hospice residents audit frequency: 3
ADL audits: 3
Oxygen orders audit frequency: 3
Call light audit frequency: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 27, 2025
Visit Reason
A complaint investigation was conducted for complaints #126415-C, #126573-C, #126717-C and a facility reported incident #126617-I from February 11, 2025 to February 27, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Complaint investigation for complaints #126415-C, #126573-C, #126717-C and facility reported incident #126617-I; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 18, 2024
Visit Reason
A complaint investigation for complaint #124276-C and facility reported incident #124775-I was conducted from November 12, 2024 to November 18, 2024. A revisit was also conducted for the survey ending on September 17, 2024.
Findings
The facility was found to be in substantial compliance with no non-compliance found during the revisit.
Complaint Details
Complaint investigation for complaint #124276-C and facility reported incident #124775-I with no non-compliance found; facility in substantial compliance.
Report Facts
Complaint number: 124276
Incident number: 124775
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 18, 2024
Visit Reason
A complaint investigation for complaint #124276-C and facility reported incident #124775-I was conducted from November 12, 2024 to November 18, 2024. A revisit was also conducted for the survey ending on September 17, 2024.
Findings
The facility was found to be in substantial compliance with no non-compliance found during the revisit.
Complaint Details
Complaint #124276-C and facility reported incident #124775-I were investigated and found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 31, 2024
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective October 31, 2024.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 4
Oct 17, 2024
Visit Reason
Investigation of complaints #123777-C, #124044-C, #124067-C, #124069-C and Facility Reported Incident #124071-1 conducted from October 14, 2024 to October 17, 2024.
Findings
The facility failed to thoroughly investigate an allegation of physical abuse for one resident and failed to ensure residents were free from significant medication errors for six of ten residents reviewed. Additionally, the facility failed to obtain physician orders for supplemental oxygen and failed to administer medications as ordered.
Complaint Details
Complaint #124069-C was substantiated regarding the allegation of physical abuse of Resident #2. The facility failed to thoroughly investigate the allegation and failed to interview all relevant staff. The facility notified regional clinical staff, police, and the Department of Inspections, Appeals, and Licensing (DIAL).
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate an allegation of physical abuse for Resident #2. | SS=D |
| Failed to obtain physician orders for supplemental oxygen for Resident #2. | SS=D |
| Failed to administer medications as ordered for Resident #6. | SS=D |
| Significant medication errors for six residents (Residents #3, #4, #12, #13, #14, and #15) due to missed medication administrations. | SS=E |
Report Facts
Census: 84
Deficiencies cited: 6
Medication errors: 6
Missed medication administrations: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in medication error findings for missed medication administrations on 10/8/24 |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #2's care and abuse allegation |
| Staff D | Licensed Practical Nurse (LPN) | Provided statement related to Resident #2's respiratory illness but lacked information on alleged abuse |
| Staff E | Certified Nursing Assistant (CNA) | Provided statement related to Resident #2's respiratory illness but lacked information on alleged abuse |
| Staff F | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #2's care and abuse allegation |
| Regional Director of Clinical Services | Provided information on oxygen administration and investigation status | |
| Regional Director of Operations | Interviewed regarding staffing and medication administration issues on 10/8/24 | |
| Interim Facility Administrator | Informed about abuse allegation and actions taken | |
| Interim Director of Nursing (DON) | Confirmed lack of oxygen order for Resident #2 |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 15, 2024
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective October 15, 2024.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, leading to certification.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Sep 26, 2024
Visit Reason
The inspection was conducted as a result of complaint investigations (#123604-C, #123608-C, #123616-C, and #123618-C) from September 23 to September 26, 2024. Complaints #123604-C and #123608-C were substantiated.
Findings
The facility failed to provide baths for 1 out of 3 residents reviewed (Resident #1), who required assistance with activities of daily living. Documentation showed Resident #1 only received one bath in August 2024 and no documentation for September. Staff interviews confirmed that residents should receive baths twice weekly, but this was not consistently done.
Complaint Details
Complaints #123604-C and #123608-C were substantiated following the investigation conducted from September 23 to September 26, 2024.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide baths for 1 out of 3 residents reviewed (Resident #1) as required by care plan and facility policy. | SS=D |
Report Facts
Resident census: 85
Residents reviewed: 3
Bath frequency: 2
Baths received by Resident #1 in August: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Interviewed regarding bathing frequency and procedures |
| Staff B | Registered Nurse (RN) | Interviewed regarding bath aides responsibilities and scheduling |
| Staff C | Certified Nurse Assistant (CNA) | Interviewed regarding bath assignments and procedures |
| Regional Director of Clinical Services | Interviewed regarding bathing policies and care plan documentation |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 3
Sep 17, 2024
Visit Reason
The inspection was conducted as an investigation of complaints #122999-C, #123362-C, #123424-C, and facility reported incidents #123422-I and #123486-I. Facility reported incident #123486-I was substantiated.
Findings
The facility failed to update residents' care plans to reflect current levels of functioning, failed to transfer a resident requiring a mechanical lift safely, and failed to provide appropriate supervision during ambulation resulting in injury. Specific deficiencies were noted in care planning, transfer assistance, and accident prevention.
Complaint Details
The investigation was triggered by complaints #122999-C, #123362-C, #123424-C and facility reported incidents #123422-I and #123486-I. Facility reported incident #123486-I was substantiated.
Severity Breakdown
SS=D: 2
SS=G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to update resident care plans to reflect current level of functioning for 1 of 4 residents reviewed (Resident #1). | SS=D |
| Failed to transfer a resident who required a mechanical lift in a safe manner for 1 of 3 residents reviewed (Resident #2). | SS=D |
| Failed to provide appropriate supervision with ambulation that resulted in injury for 1 of 4 residents reviewed (Resident #4). | SS=G |
Report Facts
Census: 85
Deficiency count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | C.N.A. | Named in fall incident involving Resident #4 where failure to use gait belt led to resident injury; employment terminated due to this and prior similar incident. |
| Staff B | C.N.A. in orientation | Witnessed Resident #4 fall in bathroom; reported lack of gait belt use and inadequate supervision. |
| Staff C | C.N.A. | Involved in transferring Resident #1 using EZ Stand lift contrary to care plan instructions. |
| Staff D | C.N.A. | Involved in transferring Resident #1 using EZ Stand lift; not trained to buckle leg harness. |
| Staff E | Physical Therapy Aide | Observed unsafe leg positioning during transfer of Resident #2. |
| Staff F | Corporate Nurse | Reported facility had three EZ Stand lifts, one with broken shin strap. |
| Staff G | Maintenance | Assigned to repair broken shin strap on EZ Stand lift. |
| Staff H | LPN | Provided care to Resident #4 post-fall; indicated resident remained in bed due to fall and non-weight bearing status. |
| Staff I | Physical Therapy Assistant | Reported no therapy evaluation request for Resident #1's changed transfer needs. |
| Staff J | Director of Nursing | Provided education on gait belt use after Resident #4 fall; explained transfer evaluation process. |
| Staff K | LPN | MDS Coordinator; unaware staff were using EZ Stand for Resident #1 transfers. |
| Staff L | RN-CO-MDS Coordinator | MDS Coordinator; unaware staff were using EZ Stand for Resident #1 transfers. |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 4, 2024
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective August 30, 2024.
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 5
Aug 1, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of complaints #122179-C, #122180-C, #122367-C, and #122374-C.
Findings
The facility was found to have deficiencies related to resident rights, including failure to treat residents with respect and dignity, inadequate response to call lights, and failure to inform residents about medication changes and treatment decisions. Complaints #122179-C and #122180-C were substantiated, while #122367-C and #122374-C were not substantiated.
Complaint Details
Complaints #122179-C and #122180-C were substantiated, involving resident rights violations and staff mistreatment. Complaints #122367-C and #122374-C were not substantiated.
Deficiencies (5)
| Description |
|---|
| Failure to treat residents with respect and dignity, including inappropriate comments by staff and failure to provide timely pain medication to Resident #78. |
| Failure to respond timely to call lights and inadequate staff supervision during toileting for Resident #13 and Resident #4. |
| Failure to inform residents of new medications and involve them in treatment decisions, as evidenced by Resident #41. |
| Failure to coordinate PASARR assessments and update resident care plans accordingly, as noted for Resident #13. |
| Failure to submit complete and accurate payroll-based journal staffing data, including omission of agency staff hours. |
Report Facts
Resident census: 84
Deficiencies cited: 5
Resident Brief Interview for Mental Status (BIMS) scores: 15
Dates of complaint investigations: Complaints investigated from July 29, 2024 through August 1, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in findings related to mistreatment of Resident #78 and termination following investigation |
| Staff E | Licensed Practical Nurse (LPN) | Reported conversation with Resident #78 and involvement in complaint investigation |
| Staff F | Certified Nurses Aide (CNA) | Witnessed conversation with Resident #78 and involved in complaint investigation |
| Staff G | Certified Nursing Assistant (CNA) | Involved in complaint investigation regarding Resident #4 |
| Staff H | Certified Nursing Assistant (CNA) | Involved in complaint investigation regarding Resident #4 |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding call light response times and medication communication |
| Administrator | Administrator | Reported termination of Staff A and provided information on complaint investigations and staffing |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 27, 2024
Visit Reason
A revisit for the survey ending May 9, 2024, investigation of Complaints #121386-C and 121166-C was conducted from June 25, 2024 to June 27, 2024.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective May 23, 2024. DPNA was not effectuated.
Complaint Details
Investigation of Complaints #121386-C and 121166-C.
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
May 9, 2024
Visit Reason
The inspection was conducted as a result of investigation of Complaint #120607-C and Facility Reported Incidents #120020-I and #120367-I from May 7 to May 9, 2024.
Findings
The facility failed to complete an accurate assessment and provide intervention after a fall for one resident, and failed to provide appropriate supervision to ensure safety for three residents. Deficiencies were substantiated related to quality of care and free of accident hazards.
Complaint Details
Complaint #120607-C was substantiated. Facility Reported Incidents #120020-I and #120367-I were substantiated, with #120367-I substantiated without additional deficiencies.
Severity Breakdown
Level D: 1
Level G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to complete an accurate assessment and provide intervention after a fall for 1 of 4 residents reviewed (Resident #4). | Level D |
| Failure to provide appropriate supervision to ensure safety for 1 of 3 residents reviewed (Resident #4). | Level G |
Report Facts
Residents reviewed: 4
Residents reviewed: 3
Census: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Agency Nurse | Named in relation to poor judgement using mechanical lift and resident care |
| Staff B | Certified Nursing Assistant | Named in relation to resident fall and lack of gait belt |
| Director of Nursing | Director of Nursing | Interviewed regarding gait belt use and supervision |
| Administrator | Administrator | Interviewed regarding staff actions and incident |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 2, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction, indicating acceptance of a credible allegation of substantial compliance and certification of the facility in compliance effective April 1, 2024.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, resulting in certification of compliance effective April 1, 2024.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 7
Mar 25, 2024
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#115592-C, #117109-C, #118198-C, #118862-C, and #119464-C) regarding alleged violations at Lantern Park Specialty Care.
Findings
The facility failed to properly report and investigate alleged drug diversion and medication errors, maintain accurate medication records, and provide adequate assistance with activities of daily living and wound care for residents. Multiple deficiencies were identified related to medication administration, investigation of alleged violations, ADL care, treatment of pressure ulcers, bowel/bladder care, pharmacy services, and food sanitation.
Complaint Details
The investigation was triggered by complaints #115592-C (not substantiated), #117109-C, #118198-C, #118862-C, and #119464-C (all substantiated). The facility failed to meet requirements related to reporting alleged violations, investigating medication errors, and providing adequate care to residents.
Deficiencies (7)
| Description |
|---|
| Failure to report and investigate alleged drug diversion and medication errors timely and accurately. |
| Medication administration errors including missing doses and inaccurate documentation for Resident #18. |
| Failure to provide adequate bathing assistance for dependent residents. |
| Failure to provide appropriate treatment and services to prevent and heal pressure ulcers. |
| Failure to ensure timely emptying and care of urinary catheter for Resident #1. |
| Failure to provide proper pharmacy services including medication administration audits and documentation. |
| Failure to maintain food procurement, preparation, serving, and sanitation standards. |
Report Facts
Resident census: 84
Medication doses missing: 6
Medication tablets left: 49
Medication doses dispensed: 60
Bathing assistance frequency: 2
Wound treatment audits: 4
Medication audits: 4
Food service sanitation audits: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN) | Reported missing Tramadol doses and concerns about medication documentation |
| Staff E | Assistant Director of Nursing | Revealed medication discrepancies were addressed immediately |
| Staff G | Corporate Consultant | Confirmed missing doses of Tramadol and facility's internal investigation |
| Staff F | Certified Medication Assistant (CMA) | Confirmed initials on medication records and transfer of documentation |
| Staff R | Licensed Practical Nurse (LPN) | Interviewed regarding narcotics book discrepancies |
| Administrator | Administrator | Interviewed regarding medication error investigations and missing documentation |
| Staff K | Certified Nursing Assistant (CNA) | Reported missed baths and shower assistance |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed about narcotics documentation and missing doses |
| Staff L | Certified Medication Assistant (CMA) | Revealed PRN medication was not tracked properly |
| Staff I | Dietary Aide | Observed during dining room hygiene violations |
| Staff J | Certified Nursing Assistant (CNA) | Observed during dining room hygiene violations |
| Staff H | Dietary Aide | Observed during dining room hygiene violations |
| Staff A | Dietary Aide | Revealed dietary aides assisted with food service and hygiene |
| Staff F | Certified Medication Assistant (CMA) | Confirmed medication documentation transfer |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 19, 2023
Visit Reason
This document is a Plan of Correction related to deficiencies cited during a prior survey event identified as #OVOY11.
Findings
The document references deficiencies from a previous survey but does not provide specific findings or details of deficiencies within this report.
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 19, 2023
Visit Reason
An on-site revisit was conducted for the recertification survey ending May 18, 2023, and an investigation of Complaints #113667-C and #114145-C from July 17 to July 19, 2023.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective June 22, 2023. The Denial of Payment for New Admits (DPNA) was not effectuated.
Complaint Details
Investigation of Complaints #113667-C and #114145-C was conducted; all deficiencies were corrected.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 12
May 18, 2023
Visit Reason
The inspection was conducted as a Recertification Survey and an investigation of Complaint #112337-C, covering the period from May 15, 2023 to May 18, 2023, to assess compliance with federal regulations and investigate specific complaints.
Findings
The facility was found deficient in multiple areas including failure to provide residents and their representatives with written information about advance directives, failure to maintain confidentiality of residents' medical records, inadequate activities to meet residents' needs, failure to prevent and treat pressure ulcers, medication errors, improper storage of drugs and biologicals, and failure to maintain an effective infection prevention and control program. Corrective actions and quality assurance plans were implemented to address these deficiencies.
Complaint Details
Investigation of Complaint #112337-C conducted from May 15, 2023 to May 18, 2023. The complaint involved issues related to advance directives, confidentiality of records, pressure ulcer care, medication errors, and infection control. The complaint was substantiated with multiple deficiencies found.
Deficiencies (12)
| Description |
|---|
| Failure to ensure residents and their representatives received written information about advance directives. |
| Failure to maintain privacy and confidentiality of residents' medical records. |
| Failure to provide activities designed to meet individualized needs of residents. |
| Failure to ensure resident services maintain or improve activities of daily living related to mobility. |
| Failure to prevent and treat pressure ulcers, including failure to conduct accurate skin assessments and notify physicians timely. |
| Failure to provide written notice to residents or representatives after emergent transfers to hospital. |
| Failure to ensure medication error rate was less than 5%. |
| Failure to store drugs and biologicals in permanently affixed compartments under proper temperature controls. |
| Failure to maintain a comprehensive facility assessment to determine necessary resources for residents. |
| Failure to maintain an effective infection prevention and control program including antibiotic stewardship. |
| Failure to conduct required annual performance reviews for nursing staff. |
| Failure to maintain food safety standards including labeling and dating of food items. |
Report Facts
Census: 82
Medication error rate: 6.67
Number of residents reviewed for advance directives: 3
Number of residents reviewed for confidentiality: 6
Number of residents reviewed for activities: 35
Number of residents reviewed for pressure ulcers: 3
Number of residents reviewed for medication errors: 35
Number of residents reviewed for infection control: 82
Number of nursing staff reviewed for annual performance: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chuco Comas | Administrator | Signed the Plan of Correction document. |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 3, 2023
Visit Reason
This document is a plan of correction related to deficiencies identified in a prior survey event (event ID #6YYM11) for Lantern Park Specialty Care.
Findings
No specific deficiencies or findings are detailed in this document; it references another event ID for survey results.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 3, 2023
Visit Reason
This document is a plan of correction related to deficiencies identified during a prior survey at Lantern Park Specialty Care.
Findings
The document references deficiencies found in a previous survey event ID #6YYM11 but does not provide specific findings or details within this report.
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 3, 2023
Visit Reason
An on-site revisit of the Complaint Survey ending January 12, 2023 and the Complaint Survey ending February 20, 2023, along with an investigation of a Facility Self-Reported Incident #111887-I, was conducted from March 28, 2023 to April 3, 2023.
Findings
All deficiencies were corrected and the facility was found to be in overall substantial compliance effective March 13, 2023. The Facility Self-Reported Incident #111887-I was not substantiated. A Denial of Payment for New Admits (DPNA) was in effect from February 14, 2023 to March 12, 2023.
Complaint Details
The revisit was related to complaint surveys ending January 12, 2023 and February 20, 2023. The Facility Self-Reported Incident #111887-I was investigated and found not substantiated.
Report Facts
Denial of Payment for New Admits (DPNA) duration: 26
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 10, 2023
Visit Reason
The visit was conducted to investigate complaints #111436-C, #111443-C, and #111444-C.
Findings
The complaints investigated during the visit were found to be not substantiated.
Complaint Details
Complaints #111436-C, #111443-C, and #111444-C were investigated and determined to be not substantiated.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 7
Feb 20, 2023
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints and facility-reported incidents occurring between January 23 and February 2, 2023.
Findings
The facility was found to have multiple deficiencies related to notification of changes, care plan timing and revision, services provided meeting professional standards, ADL care for dependent residents, quality of care, treatment and services to prevent and heal pressure ulcers, and free of accident hazards/supervision/devices. Several residents were affected by these deficient practices, including issues with notification of urinary tract infections, pressure ulcers, medication administration, and fall risk management.
Complaint Details
The investigation involved complaints 110252-C, 110362-C, 110509-C, 110630-C, and 110909-C. Complaints 110362-C, 110509-C, 110630-C, and 110909-C were substantiated. Complaint 110252-C and facility incident 110513-I were not substantiated. Facility incident 110703-I was substantiated.
Deficiencies (7)
| Description |
|---|
| Failed to notify nurse practitioner and family of urinary analysis results for Resident #13. |
| Failed to update care plans for 5 of 5 residents reviewed. |
| Failed to administer medication as ordered for Resident #2. |
| Failed to provide showers/baths twice weekly for two of three residents reviewed (Residents #2 and #3). |
| Failed to document complete assessment for Resident #10 who fell and sustained a laceration to the head. |
| Failed to ensure resident environment remains free of accident hazards and provide adequate supervision and assistance devices for Residents #10 and #11. |
| Failed to prevent pressure ulcers and provide necessary treatment and services for Residents #2 and #3. |
Report Facts
Census: 84
Number of residents reviewed for care plans: 5
Number of residents reviewed for medication administration: 3
Number of residents reviewed for showers/baths: 3
Number of falls for Resident #10: 11
Number of falls on night shift: 7
Number of falls on day shift: 4
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 4
Jan 12, 2023
Visit Reason
The inspection was conducted as an investigation of multiple complaints (#107900-C, #108384-C, #108490-C, #109095-C, #109952-C) and a Facility Self-Reported Incident (#109993-I) from December 27, 2022 to January 12, 2023.
Findings
The facility was found to have substantiated complaints involving abuse, neglect, and failure to provide adequate care including bathing assistance and respiratory/tracheostomy care. Deficiencies were identified in reporting alleged violations, providing ADL care, and respiratory care, resulting in immediate jeopardy that was later removed after corrective actions.
Complaint Details
Complaints #107900-C, #108384-C, #108490-C, #109095-C, #109952-C and Facility Self-Reported Incident #109993-I were substantiated.
Deficiencies (4)
| Description |
|---|
| Failure to report alleged abuse within required timeframes and failure to implement policies to address abuse incidents. |
| Failure to provide necessary bathing assistance to 6 of 6 residents observed. |
| Failure to provide appropriate respiratory/tracheostomy care including assessment, training, and availability of supplies, resulting in immediate jeopardy. |
| Failure to provide adequate pain management for 2 of 2 residents reviewed. |
Report Facts
Facility census: 85
Residents observed lacking bathing assistance: 6
Residents reviewed for pain management: 2
Residents with substantiated abuse: 1
Residents with tracheostomy care deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN) | Mentioned in relation to tracheostomy care deficiencies and pain management observations |
| Staff H | Licensed Practical Nurse (LPN) | Documented tracheostomy tube changes for Resident #1 and trained by Staff I |
| Staff I | Trained Staff H on tracheostomy tube changes | |
| Staff A | Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) | Interviewed regarding humidification and staffing issues |
| Staff C | Registered Nurse (RN) | Interviewed about tracheostomy tube care and training |
| Staff J | Certified Nursing Assistant (CNA) | Interviewed about shower completion and resident care |
| Staff K | Certified Nursing Assistant (CNA) | Interviewed about abuse incident and resident care |
| Director of Nursing | Interviewed about incident reporting, internal investigation, and corrective actions | |
| Staff G | Director of Rehabilitation | Interviewed regarding therapy orders and resident treatment |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 22, 2022
Visit Reason
A complaint investigation was conducted for multiple complaints (#105205-C, #105254-C, #106365-C, #106462-C, #107378-C, and #107491-C) from September 19, 2022 to September 22, 2022.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Investigation involved multiple complaints and the facility was found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
May 24, 2022
Visit Reason
The visit was an onsite revisit to verify compliance following a prior inspection.
Findings
The facility was found to be in substantial overall compliance effective May 20, 2022.
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Apr 20, 2022
Visit Reason
The investigation was conducted due to complaints #103616-C, #103618-C, #103636-C and Facility Self-Reported Incidents #102736-I and #103713-I between March 30 and April 20, 2022.
Findings
The facility failed to employ or engage staff with adverse actions as required by regulations, specifically related to Staff K who had a history of dependent adult abuse and was not properly evaluated before employment. Additionally, the facility failed to provide necessary ADL care including incontinence and catheter care for dependent residents, resulting in inadequate personal hygiene and care.
Complaint Details
Complaints #103616 and #103618 were substantiated. The investigation found that Staff K had a criminal and dependent adult abuse history that was not properly addressed before employment. The facility was instructed to follow background check policies and suspended Staff K pending DHS evaluation. Additionally, deficiencies in ADL care for dependent residents were documented.
Severity Breakdown
S=S=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Not employ/Engage Staff with Adverse Actions | S=S=D |
| ADL Care Provided for Dependent Residents | S=S=D |
Report Facts
Census: 80
Complaints investigated: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Registered Nurse (RN) | Named in deficiency for not properly evaluated background check and adverse actions |
| Staff G | Non-CNA | Failed to provide peri care to Resident #6 |
| Staff A | Failed to complete peri care or catheter care for Resident #4 | |
| Staff D | Failed to provide peri care or catheter care for Resident #5 | |
| Staff E | CNA | Failed to provide peri care from front for Resident #5 |
| Staff F | CNA | Failed to provide peri care from front for Resident #5 |
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 6
Nov 18, 2021
Visit Reason
The inspection was conducted as an annual health survey and investigation of complaints and facility-reported incidents.
Findings
The facility was found deficient in multiple areas including failure to follow physician orders for catheter changes, unsafe storage of oxygen tanks, insufficient nursing staff response to call lights, and inadequate infection prevention and control practices. The facility reported a census of 71 residents during the survey.
Complaint Details
The investigation of complaint #96362-C and facility-reported incident #96363-I did not result in facility deficiency. Other complaints (#97237-C, #98170-C, #97025-I, #98174-I, #98309-I) were related to the annual survey findings.
Severity Breakdown
SS=D: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to follow physician orders to change a urinary catheter for one resident requiring catheterization. | SS=D |
| Failure to ensure safe wheelchair positioning and secure oxygen tanks properly, posing accident hazards. | SS=D |
| Failure to answer call lights in a timely manner for two of twenty residents reviewed. | SS=D |
| Failure to maintain an infection prevention and control program, including improper catheter care and wound care for multiple residents. | SS=E |
| Failure to have a policy regarding proper oxygen storage. | SS=D |
| Failure to maintain sufficient nursing staff with appropriate competencies and skills. | SS=D |
Report Facts
Resident census: 71
Number of residents reviewed for call light response: 20
Number of residents reviewed for wheelchair safety: 5
Number of residents reviewed for infection control: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in wheelchair positioning and oxygen tank storage deficiency. |
| Staff L | Certified Nursing Assistant (CNA) | Interviewed regarding catheter change procedures and oxygen tank storage. |
| Staff M | Certified Nursing Assistant (CNA) | Interviewed regarding catheter change procedures and oxygen tank storage. |
| Staff N | Certified Nursing Assistant (CNA) | Interviewed regarding catheter change procedures and oxygen tank storage. |
| Staff D | Registered Nurse (RN) | Interviewed regarding oxygen tank storage and infection control practices. |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding oxygen tank storage and infection control practices. |
| Director of Nursing | Director of Nursing (DON) | Reported facility policies and expectations related to catheter changes, call light response, and infection control. |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Feb 15, 2021
Visit Reason
An investigation of a Facility Self-Reported Incident #95716 was completed between 2/11/2021 and 2/15/2021.
Findings
The investigation was completed and the incident was not substantiated.
Complaint Details
Investigation of a Facility Self-Reported Incident #95716 was completed and found not substantiated.
Report Facts
Total residents: 70
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 0
Dec 22, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 0
Dec 3, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 12/3/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total Residents: 66
Inspection Report
Routine
Census: 75
Deficiencies: 0
Jul 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 75
Inspection Report
Routine
Census: 73
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 8, 2020
Visit Reason
The inspection was conducted as a result of investigations of complaints #90402-I and #90403-C.
Findings
No deficiencies were cited as a result of the investigations.
Complaint Details
Investigations of complaints #90402-I and #90403-C were conducted with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 6
Jan 30, 2020
Visit Reason
The inspection was conducted as part of the facility's recertification survey and investigation of Complaint #873331, which was not substantiated.
Findings
The facility was found deficient in several areas including failure to provide quarterly statements for residents' personal funds, lack of signed physician orders for residents' code status, failure to submit required PASARR Level II screenings, incomplete care plans, and inadequate monitoring and documentation of residents' conditions and treatments.
Complaint Details
Complaint #873331 was investigated during the recertification survey and was not substantiated.
Deficiencies (6)
| Description |
|---|
| Failure to provide quarterly statements for residents' personal funds (Resident #55). |
| Lack of signed physician orders for residents' code status for two new admissions (Residents #78 and #287). |
| Failure to submit a Level II PASARR screening for Resident #9 within required timeframes. |
| Failure to coordinate PASARR assessments and incorporate recommendations into resident care plans. |
| Care plans for residents #30 and #55 were not updated to reflect current conditions and treatments, including use of antipsychotic medications and urinary tract infections. |
| Failure to address hospitalizations for urinary tract infections in resident care plans. |
Report Facts
Resident census: 82
Resident #55 Minimum Data Set (MDS) 5 Day Assessment date: Jan 14, 2020
Resident #78 Admission date: Dec 23, 2019
Resident #287 Admission date: Jan 15, 2020
Resident #9 Admission date: May 4, 2019
Resident #9 PASARR determination date: May 21, 2019
Resident #9 PASARR short-term approval expiration: Nov 17, 2019
Resident #30 MDS Assessment date: Nov 1, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Reported resident upset about billing and personal funds issues. | |
| Business Office Manager | Reported Medicaid payor source and issues with resident client participation updates. | |
| Licensed Practical Nurse (LPN) | Reported checking orders and locating advance directives. | |
| Director of Nursing (DON) | Reported inability to locate signed admission orders and care plan deficiencies. | |
| MDS Nurse | Reported failure to include specific reasons for antipsychotic medication use in care plans. | |
| MDS Coordinator | Reported monitoring care plans and PASARR compliance. |
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